Impaired Risk Review...
Watchful Waiting/Active Surveillance For Prostate Cancer
Robert Goldstone
December 2017

Getting insurance for individuals with cancer has its challenges.  What was the cancer, how was it treated, how long has it been since therapy, what has the follow-up treatment been?  The keyword in these scenarios is treatment.  What if there has been no treatment at all?   Prostate cancer is one of those processes where both doctors and patients may opt to defer treatment because of the slow growing nature of the disease, but the unknown outcome makes getting insurance even more problematic.

The terms “watchful waiting” and “active surveillance” are often used interchangeably, but in fact are somewhat different.  Watchful waiting generally refers to cases where treatment of the disease might result in a series of life threatening complications that an individual might succumb to or where the treatment of the disease might not confer any added mortality benefit given the person’s overall health (or lack of it).  Active surveillance is the choice to carefully monitor disease status with testing with the understanding that a definitive treatment may be undertaken if the disease advances.  This generally is an understanding between doctor and patient where the natural tendency to advance to treatment is tempered by the morbidities that treatment might bring, especially if the disease may not advance at all or can be treated later on without mortality consequences.

Prostate cancer is perhaps the most controversial of the waiting/surveillance scenarios, since there isn’t universal agreement on its use nor on the exact set of circumstances when it is employed.  In fact, even the simple act of screening for prostate cancer is quite controversial.  Whereas many doctors include it in their cancer screening tests and the insurance industry requires it in the examination bloodwork, The U.S. Preventative Task Force (USPSTF) actually (and bluntly) recommends against prostate specific antigen (PSA blood testing) screening for prostate cancer.  The reasons behind it are enough for a separate article in and of itself, but the Task Force concluded that the benefits of PSA screening do not outweigh the harms.

What are these “harms”?  The Task Force stated that the primary goal of prostate cancer screening is to reduce deaths due to prostate cancer and increase length of life.  It stated that the risk of overdiagnosis of prostate cancer was significant.  That prostate biopsies cause “a moderate or major problem” in terms of complications in many men.  That treatment such as surgery, radiation, and hormone therapy cause a set of symptoms that are unacceptable to men, especially if their prostate cancer is early stage and there is a likelihood that they would have eventually died of another unrelated cause.  Prostate surgery or radiation may result in impotence, incontinence, erectile dysfunction, gynecomastia, and other local complications.  All are fair points, excepting the outcome of death from prostate cancer is significant and the American Cancer Society estimates one in 39 males overall will die from the disease.  

All that said, underwriting comes across cases where active surveillance has been the chosen path.  Are all cases of untreated prostate cancer declined?  If not, which cases are the most amenable to a life insurance offer?  What is the underwriter looking for in such cases?  And which characteristics are the most favorable ones to obtaining an offer?

The American Society of Clinical Oncology (ASCO) has a detailed recommendation for the use of active surveillance.  But it is more limited to pathology.  Let’s go through the things a doctor (and secondarily an underwriter) looks at one point at a time:

  • Localized prostate cancer.  The recommendation pertains to cancer located entirely within the prostate gland (no spread or outside invasion) and a Gleason score of six or less.  (Gleason score is based on aggressiveness of the pathology of the tumor).  Some Gleason scores of seven (they range from 2-10) may be included, but their risk is greater.
  • PSA levels.  Higher PSA levels generally indicate a higher suspicion the disease is a more aggressive cancer.
  • Age.  In older males (such as age 70 or older), the odds increase that a man will “outlive” his prostate cancer, meaning the progression is slow enough that death will occur from an unrelated cause or illness.  In males under 60, that likelihood decreases.
  • Stage.  Cancers should be stage 1 or stage 2a.  Rarely 2b is considered.  
  • Stable testing.  PSA levels that are serially drawn should not be elevating.  When prostate biopsies are done, they show no advancement of disease (the ASCO suggests serial biopsies).
  • Regular follow-up, digital rectal examinations, and continuous assessment.

When all is said and done, there is not universal agreement on which cases can be taken and at what rates by insurers.  The best cases are older males who have stable PSAs, a favorable biopsy result, and overall good health.  Those cases with several years of stability may be taken standard in certain cases.  The most difficult to insure are the men who have higher Gleason scores, are younger, and with higher PSAs.  Insurers will likely postpone or outright decline these cases, as the risks are too high to assume.  

The universal agreement in watchful waiting/surveillance is the need for frequent and comprehensive follow-up.  Regularly scheduled exams, blood work, and biopsies if indicated are what make this method work, whether clinically or from an underwriting perspective.   

Author's Bio
Robert Goldstone, MD, FACE, FLMI
MD, FACE, FLMI, board certified internist and endocrinologist, was most recently vice president and chief medical officer for Pacific Life and Pacific Life and An­nu­ity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endo­­­crinology and has written monthly for Broker World since 1991. Goldstone can be reached by ­telephone at 949-943-2310. Emaill: drbobgoldstone@yahoo.com.















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